General

 

The general rules and recommendations for the transportation of sick patients apply to babies and children as well as for adults. However, the transportation of a sick infant or child differs in many matters from that of adult patients. 

All infants and children must be transported with at least one accompanying parent or other relative if at all possible.

The interest of the parents is evident regardless of the child's age. Furthermore, most children – even if just a few months old – will be quieter when a parent is present, and the parents will know their children's reactions. If a child is being transported while awake, then the parent’s presence is often a good help to ensure successful transportation. This means that space for at least one parent should always be prioritised, and this also applies to transportation by air ambulance.

The sick baby and child

Newborns and infants have anatomical and physiological differences to bigger children and adults, requiring special attention.

Airways and breathing

Newborns and young children have relatively narrow upper airways and decreased respiratory reserve capacity. A prerequisite for transport by commercial flight is that the child is in a respiratorily optimal and stable condition.

A child with stridor or other signs of compromised upper airways should be transported only if clearly needed. The child should in such a situation always be accompanied by a member of staff who is experienced in the management of difficult airways in a child. In practice, this usually means transportation by an air ambulance.

It is possible before transportation to assess a child's oxygen during flight by testing with FiO2 0.15. However, this is only possible at a few places in the world, and therefore the following rule is used (see also section on preterm): Newborns and young children, who at ground level have oxygen saturation <95%, will often require supplemental oxygen during flight, although they are otherwise stable.

Skull pneumatisation develops gradually during the first years of life; therefore small children usually have no problems with pressure equalisation. If symptoms due to pressure equalisation develop anyway, then they can be alleviated as they are in older children and adults. Babies can often be alleviated by breastfeeding or by drinking from the bottle.

In otitis media, the rules for flying are the same at all ages (see Chapter 11).

Circulation

Children with unstable circulation should not be transported by commercial flight.

Children with a congenital heart disease may have habitual low oxygen saturations, also after surgical repair. Some will even be sensitive to supplemental oxygen. Planning the transportation of such children should therefore always be in collaboration with an expert in paediatric cardiology, no matter if the transport is by commercial flight or air ambulance.

Neurology

Newborns and young children often have more seizures than adults.

After a febrile seizure, a child can travel on a commercial flight after at least one day without fever. A child with known epilepsy is fit for flight at the earliest one day after a seizure on a commercial flight, and only if the child is in its normal condition. For children with first-time afebrile convulsions, an individual assessment in consultation with a specialist in paediatrics or paediatric neurology should be made. Parents or a medical companion for a child who is to be transported after a seizure must be instructed in the emergency treatment of seizures, for example, with rectal diazepam or bucchal midazolam.

Fluid balance

Young children have a higher fluid turnover per kg body weight than adults. The basic requirement on the ground is about 150 ml / kg / day in a newborn after the first week of life. After the first couple of months, the daily need can be estimated as 100 ml / kg for the first 10 kg body weight, 50 ml / kg of weight 10-20 kg and 20 ml / kg of weight > 20 kg. Thus, for a 15 kg child, the fluid requirement is 10 x 100 ml + 5 x 50 ml = 1250 ml.

Fluid loss in aircraft cabins is larger than on the ground, and fluid requirements are similarly higher than that previously specified. One should therefore ensure that the child can seamlessly consume plenty of fluids before air travel or secure the opportunity to supplement via nasogastric tube or intravenous access. This also applies to small children recovering from gastroenteritis. For prolonged flights (> 4 hours), the child should have been without fever, vomiting, and diarrhoea and able to consume plenty of fluids for at least a day before the flight. Before transportation and during prolonged transportation, urine production is a good measure of the sufficiency of fluid intake. Young children have a normal urine output of 1-2 ml per kg per hour. Urine production can be estimated on whether the baby has wet diapers several times a day or not.

Temperature

Babies and infants get easily hypothermic and when planning transportation one needs to consider how to avoid hypothermia. For sick newborns this generally requires transportation in an incubator.

Transport of preterm and sick newborns

Premature and sick neonates should where possible be treated locally. Transportation in the neonatal period should only be made if the child's medical needs exceed local capabilities. In such cases there will usually be a need for an air ambulance.

Premature babies can usually be transported seamlessly with commercial flights when they can maintain their temperature outside the incubator and do not require support of ventilator or supplemental oxygen for 1-2 weeks. This is often possible in uncomplicated cases at a weight of approximately 2000 g and a gestational age of 35-36 weeks, depending on how early the baby was born. When transporting such a child, it should always be possible to administer oxygen supplementation during the flight, as most will need this. In planning such transport, it must be ensured that the child's haemoglobin level is acceptable for flight (minimum 5.5 mmol / l = 8.8 g / dl). Premature babies often develop a physiological, relative anaemia in the first months of life, and this is aggravated by the need for frequent blood sampling.

Children should always be accompanied by a physician and/or a nurse with neonatal experience.

Transportation in incubator

The transport of babies in incubators normally requires an air ambulance.

Most commercial airlines, especially in Europe, no longer accept incubators. Incubator transports, whether on an air ambulance or by commercial flight, requires medical staff with neonatal experience, which is familiar with the transport incubators function, including electricity needs, heat, humidity, and oxygen regulation. It must be ensured that the incubator can be clamped securely during transport, and the child must be secured in the incubator.

The transport of healthy newborns

Healthy newborns born at term can usually be transported seamlessly with commercial flights after 1-2 weeks. One should not accept transport earlier due to the risk of respiratory and circulatory problems and an increased risk of hypothermia. This is conditional on the transition from foetal to extra-uterine physiology. Some airlines do not accept newborns before 44 completed weeks of gestation, i.e. four weeks after the expected date.

Equipment for transport of babies and infants on commercial flights

For transportation by air ambulance, equipment will be determined by the individual child's needs, but as a rule an air ambulance should be equipped and staffed to meet the standards of a neonatal or paediatric intensive care unit.

When transporting infants and young children on commercial flights, the following list of equipment is not necessary in all cases, but it is necessary to consider each of these topics when planning the transport.

Equipment that may be required when transporting newborns and young children

by commercial flight:

• Lift or chair for the baby so that it can be carried easily and safely, and fastened during

   transportation by car and plane. During take-off and landing, infants can often sit secured by belt

   on a parent's chest. These belts are standard equipment on airliners.

• Warm clothes for small children and infants, including a hat and blankets to protect against

   cooling.

• Monitoring equipment: As a minimum, a pulse oximeter with probes appropriate to the child's size

   should be included. In some cases, ECG monitoring is appropriate.

• Ventilation equipment with a mask and a self-inflating bag in an appropriate size for the child.

• If a child has airway secretions, or is prone to gastro-oesophageal reflux or significant

   regurgitation then a suction unit and suction catheters in the appropriate size should be

   available.

• When transporting infants and newborns, a thermometer is needed.

• Thermo-bag for the storage of breast milk/formula.

• If the child drinks from a bottle, then bottles and teats are needed.

• If the child is fed through a nasogastric tube, then syringes and extra tubes in the appropriate

   sizes are needed.

• If a child has a tracheostomy, then extra tubes in the adequate sizes should be available.

If the child requires any intensive treatment, then it is usually best to transport the child by air ambulance. A child requiring intermittent intravenous drug delivery during transport, for example anti-biotics, can be transported by commercial flight. In such cases, syringes and devices for the reinsertion of an intravenous line are needed.

High-risk transports

Only children in a stable condition should be transported by commercial flight.

Some conditions are associated with a high risk of complications during transport and transport in such cases should only be planned if absolutely needed. Such transports should be by air ambulance.

Examples of such conditions are:

• Preterm babies < 35 completed gestational weeks and/or < approximately 2000 g.

• Newborns at term until 7 (to 14) days after birth.

• Stridor.

• Need for continuous CPAP or ventilator*.

• Need for continuous circulatory support.

• Frequent seizures or severe dystonia.

*Children in chronic need of ventilatory support, i.e. by mask or tracheostomy, can normally, when in their habitual condition, be transported by commercial flight.

Logistics

Children born abroad and who will subsequently be repatriated need a temporary or emergency passport before any transport can be arranged. This is done in most countries in cooperation with the local embassy or consulate. Since the procedure can take time, it is appropriate to begin working on this as early as possible in order not to delay repatriation.

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